1. Theory-based Approaches to Formative Approaches: translating observations into research questions/possible techniques Basil Safi, MPH, PE, CHES Kathmandu, Nov 8, 2011

2. Overall Approach Defining strategic health communication Why formative evaluation? Why “theory-based”? Important concepts from social & behavioral design and implementation Group exercise

3. Strategic Communication Strategic communication is a process carried out with the active participation of stakeholders and beneficiaries that addresses a long-term vision and affects the causes of as well as the barriers to behavior change.

4. We need to recognize the multiple layers that influence individual behavior Social Ecological Framework

5. Engaging Communities for Healthy Nutrition Behaviors Mass media Community mobilization Interpersonal communication and counseling Capacity building Advocacy Working at Multiple Levels for Greatest Impact

6. Why Formative Evaluation? Central tenet of behavior change interventions: KNOW YOUR AUDIENCE Demographically – Age – Education – Gender – Religion – Political views – Residence – Health literacy

7. Knowing your Audience Psycho-graphical profile (KAP) – Prevailing attitude – Knowledge – Risk perceptions – Efficacy beliefs – Perceived barriers – Priorities Communication profile – Interpersonal ties – Media use patterns – New technology adoption – Access to information

8. Knowing your Audience Behaviorally – Prior behaviors (attempted change before?) – Readiness for adoption of new behaviors Culturally – Social norms – Social support (vs. isolation) – Cultural traditions – Obligations Structurally – Environmental facilitators and constraints – Access to services

9. Exposure to CBAIC TV spots increases level of perceived social influence and interaction KAP 2009 Household Survey Base: All respondents *Unpaired t-tests, p<.0001

10. Presence of Team Flu Burung in community increases perceived social influence KAP 2009 Household Survey Base: All respondents *Unpaired t-tests, p<.0001

11. Reach & Touch Targeting – Reaching the audience “where they live” – Tapping into the appropriate communication channel or venue – Purpose: to enhance exposure Tailoring: Crafting persuasive messages that – Resonate – Inspire – Motivate

12. Reduction in early childhood mortality and stunting Baseline trend Current direction

13. Reduction in early childhood mortality and stunting with Suaahara intervention Baseline trend With health intervention

14. Reduction in early childhood mortality and stunting through health intervention and current direction meeting at later point Baseline trend With health intervention Zero nutrition related infant deaths Shared vision

15. Awareness Putting theories to work Action Comprehension & Risk Perception Decision-making Intention Where is your audience with respect to the desired action? What information or messages do they need at that stage? Maintenance

16. Stages of Behavior Change Where is your audience with respect to the desired action? What information or messages do they need at that stage? Awareness of H1N1 flu Vaccination Knowledge of transmission modes & realistic risk perception Considering vaccinating herself Intention to make an appointment Takes her husband and 3 yr old daughter for vaccination and advocates to family/friends Audience: 30 yr old pregnant woman

17. Formative Evaluation Questions in the Suaahara Campaign Targeting Question: What salient communication channels need to be employed? – Radio, mobile phones, interpersonal sources? Segmentation Question: Who are the primary audiences? – Pregnant women – illiterate moms – Fathers – Others? – Who influences them (secondary audiences)? Tailoring Question: What messages will be designed?

18. E.g. of a Spacing Campaign The same message is crafted differently for different audiences, while retaining its essence TV Spots, Radio spots, Billboards, Poster and wall paintings

19. Regional Variations E.g. Urban/Rural; East/West Pretesting visuals and content is critical – Appeal, Comprehension, Intent to Act, Culturally appropriateness

20. Design guidelines 1.What are the various levels of knowledge we need the intended audience to acquire? 2.What attitudes or perceptions need to be shifted to facilitate to social and behavioral change? 1.What are the general practices that we should promote (adopting)? 2.What are the specific practices that we should enhance, modify and / or change? 3.What is our definition of high risk practices ? 4.What should be the indicators above ? How to go about the measurement?

21. How Does Communication Affect Intention? Enabling ? COMM CCOOMMMMUNICATIONUNICATIONCCOOMMMMUNICATIONUNICATION Knowledge & Skills Intention EnvironmentalConstraints Behavior Reinforcement Advocacy PromotionInstruction

22. How Does Communication Affect Intention? Enabling Ideation COMM CCOOMMMMUNICATIONUNICATIONCCOOMMMMUNICATIONUNICATION Knowledge & Skills Intention EnvironmentalConstraints Behavior Reinforcement Advocacy PromotionInstruction

23. Defining Ideation Ideation is defined as new ways of thinking and the diffusion of those ways of thinking by means of communication and social interaction in local, culturally homogeneous communities.

24. Ideation Theory of Communication Knowledge Attitudes Self- Image Perceived Risk Perceived Efficacy Norms Emotion Social Influence Personal Advocacy BEHAVIOR Implies simultaneous effect of all influences. Implies that communication can affect all of these factors. (Kincaid, Figueroa, Storey, & Underwood, 2001)

25. E.g. Perceptions of Diarrhea Diarrhea is not always seen as a significant health threat Viewed as part of growing up and may even be seen as beneficial for children, except during an epidemic such as cholera Diarrhea is caused by many different exposure, so it is perceived as something that is difficult to control, especially by just boiling or treating water

26. Other perceived causes of diarrhea (1) infancy teething, (2) traumatic falls, (3) inadequate care of children, (4) imbalance of hot and cold foods or states, (5) improper diet, such as, too much fruit, eating sweets or overeating, (6) breastfeeding the child after s/he has been hungry for a while, (7) switching from treated drinking water to non-treated drinking water, (8) evil eye, and (9) mothers’ health behavior and emotional state (Nielsen et al., 2003; Goldman, Pebley, & Beckett, 2001; Iyun & Oke, 2000; McLennan, 1998; McLennan, 2000a, Olango & Aboud, 1990; Ketsela, et al., 1991; Kaba & Ayele, 2000; Jintrawet & Harrigan, 2003; Nichter, 1988)

29. Perceptions of Water Treatment Water treatment is not always perceived to have compelling health benefits. Even if you treat water at home, you may still get exposed to contaminants elsewhere Only for the weak, young, and frail

30. Case Study: Aman Titra Worked to develop a sustainable commercial model for the production, distribution and promotion of a POU chlorination product (Air RahMat), Create an enabling environment to increase access to POU products and technologies. Ati, A. Figueroa, ME, Ainslie, R., Making waves against the norm, 2009, APHA

31. Boiling as the main treatment method Ati, A. Figueroa, ME, Ainslie, R., Making waves against the norm, 2009, APHA

32. Boiling perceptions A tradition: “our parents, our ancestors boiled their drinking water, and so do we. It’s a tradition” Practical! For smart people: “people here are smart people here are smart and knowledgeable, they know that water and knowledgeable, they know that water needs to be boiled”

33. Are there other ways to make water as safe as it is after boiling? Ati, A. Figueroa, ME, Ainslie, R., Making waves against the norm, 2009, APHA

34. Percentage of households with E.coli contaminated boiled, ready to drink water Ati, A. Figueroa, ME, Ainslie, R., Making waves against the norm, 2009, APHA

35. Why would people try it? Economical, Practical Media ads enhanced the credibility of the product the product Registered/approved product

36. 3 Components of Ideation Enabling Cognitive Beliefs/Values Perceived Risk Subjective Norms Self-Image Emotional Emotional Response Empathy Self-Efficacy Social Support & Influence Personal Advocacy COMM CCOOMMMMUNICATIONUNICATIONCCOOMMMMUNICATIONUNICATION Knowledge & Skills Intention EnvironmentalConstraints Behavior Reinforcement Advocacy PromotionInstruction

37. Factors Influencing Behaviors Intentions to perform the behavior Environmental constraints preventing the behavior Skills necessary to perform the behavior Behavioral beliefs and perceived consequences (attitudes) Perceived normative pressure Self-image: self-standards and sanctions Emotional reactions Self-efficacy (perceived capability and confidence )

38. Group Exercise: The “Yes, but…” Game Objectives To elicit significant barriers that impede ability to change behaviors To categorize barriers into meaningful themes Assumption –Sometimes, people may be reluctant to discuss their barriers –People may not be consciously aware about the barriers

39. Example 2: The “Yes, but…” Game Method Provide a sentence Ask audience to complete the sentence with the phrase, “Yes, but….” Example “Always wash your hands before you eat” Yes, but…….. –…… the water is often dirtier than my hands –……. there is a severe water shortage

40. Example 2: The “Yes, but…” Game Develop themes It may be possible to categorize barriers according to levels. For example, barriers against breastfeeding: Individual level: lack of perceived importance Interpersonal level: family may not support breastfeeding after child is a couple of months old Normative level: others may think I am weird Structural level: I am too far away from home in the day time because I need to get firewood

41. Example 2: The “Yes, but…” Game Develop themes It may be possible to categorize barriers according to other factors. For example, barriers against immunization of new-born babies Psychological: it is too traumatic Cost: it takes too much money to get on a bus and get to the clinic Structural: clinic is too far away Social: no one else seems to be doing it

42. Example 2: The “Yes, but…” Game Group Themes 1)Use of fertilizer for your crops 2)Build a village latrine 3)Exclusively breastfeed infant for first 6 months 4)Seek medical attention at the first signs of wasting 5)Raise chicken as family protein source